Uterine prolapse in Tunisia

Causes?

The pelvic floor is a structure made up of muscles, ligaments and connective tissue that mainly performs two functions:
Supports organs such as uterus, bladder, rectum.
It allows the passage of the urethra, the vaginal canal and the last part of the rectum.
Pelvic organ prolapse occurs when the pelvic floor weakens and is no longer able to provide adequate support.
If the musculo-ligamentous structures that make up the pelvic floor are injured or give way, it is likely that their function of supporting the pelvic organs will fail, causing them to descend downward.
Uterine prolapse consists of the downward sliding of the uterus and its consequent entry into the vagina; it can take varying degrees and in the most advanced forms it can come out of the vestibule of the vagina and be visible on the outside.

Symptoms

Symptoms of uterine prolapse include:
Sensation of pelvic heaviness.
Perception of movement of the viscera in the groin, especially when changing position.
Genital swelling and discharge from the uterus through the vagina.
Discomfort or pain during sexual intercourse.
Incomplete urination, increased frequency and stress urinary incontinence (as a result of coughing, sneezing, some efforts, …).
Difficulty evacuating.
The most striking symptom of advanced uterine prolapse is the protrusion of the uterus out of the vagina. In less severe cases this does not occur, but the perception of the presence of a foreign body in the groin or a feeling of heaviness or pelvic discomfort may be reported. This discomfort can be accentuated when standing, walking, changing position or during sexual activity.
Urological symptoms are common and are manifested by:
The inability to completely empty the bladder while urinating.
Or, conversely, urinary incontinence.
It is important to remember that in cases of mild uterine prolapse, the condition can also be asymptomatic.

Complications and associated pathologies

A complication that can occur during a uterine prolapse is vaginal ulcer: the protrusion of the uterus into the vagina causes chronic irritation of the vaginal walls that can eventually lead to the formation of an ulcer. The ulcer may manifest as bleeding and may become infected.
Incomplete emptying of the bladder can lead to recurrent cystitis.
The weakening of the pelvic floor predisposes to the development, sometimes at the same time, of:
bladder prolapse,
rectal prolapse.

Diagnostic

The diagnosis of uterine prolapse is quite simple: the descent of the uterus into the vagina is indeed confirmed during a normal gynecological visit. In order to properly frame the case of the examined patient and to diagnose other possible concomitant disorders, it is necessary to take an accurate anamnesis and, in some cases, it may be indicated to undergo additional tests.
The number and characteristics of the patient's births, the presence or absence of menopause or any estrogen deficiency are sought through the gynecological anamnesis. Other risk factors are then taken into consideration, such as obesity, chronic constipation or the presence of other pathologies that cause an increase in abdominal pressure and any surgical intervention undergone in the pelvic region.
During the gynecological examination, the presence of uterine prolapse is evaluated and it is possible that the doctor asks the patient to stand up, since the prolapse may become more evident thanks to the action exerted by the force of gravity. Alternatively, a forced expiration with a closed glottis can be requested: this maneuver, called Valsalva, causes an increase in intra-abdominal pressure and also allows a better assessment of the prolapse.
Rarely, it may be necessary to undergo nuclear magnetic resonance for a definitive diagnosis.
It may be necessary to undergo a urological examination, especially if urination disorders are present.

Treatment

Uterine prolapse is approached differently depending on the severity of the disease.
In mild and asymptomatic forms, it may be enough to follow a few precautions to prevent the progression of the prolapse; in these cases, it is recommended to perform daily exercises that strengthen the muscles of the pelvic floor.
These exercises are called Kegel exercises, named after the American gynecologist who was the first to identify and disseminate its benefits, and consist of performing alternate contractions with the relaxation of the pubococcygeal muscles, which are the muscles that are used to attempt to interrupt the flow of urine during urination. Pelvic floor gymnastics should be practiced daily, the contraction of the muscles should be held for about 5 seconds and is followed by relaxation which lasts about twice as long. It is recommended to repeat the exercise about ten times per session and to perform three sessions per day (morning, noon and evening). Exercises should be performed after emptying the bladder and it is important to avoid overtraining which could lead to excessive muscle fatigue and therefore adverse effects.
When performed regularly and correctly, pelvic floor exercises are also effective in preventing or reducing urinary incontinence.
In the most advanced and symptomatic forms of uterine prolapse, medical and/or surgical treatments are used.
Patients with hormonal disorders, such as the decline in estrogen typical of menopause, may benefit from estrogen therapy. Indeed, these hormones contribute to determine a greater tonicity of the muscles of the pelvic floor and a better trophism of the mucous membranes.
Non-surgical remedies include pessaries, rubber or silicone devices that are placed inside the vaginal canal and help reposition the uterus, keeping it in the correct place. They offer the advantage of avoiding surgery, but on the other hand they exert a certain pressure on the tissues on which they rest and can therefore promote the formation of ulcers. They can be used in patients who do not wish to have surgery or as a temporary remedy while waiting for surgery.
The purpose of surgery is to definitively eliminate the disorders associated with uterine prolapse; there are several approaches available and the procedures mainly performed are
hysterectomy (removal of the uterus).
hysteropexy (suspension of the uterus).
The choice of the type of operation is made according to the characteristics of the patient, the presence of other pathologies of the pelvic region and the experience of the surgeon.

Prevention

Prevention of uterine prolapse in predisposed women is based on the adoption of the following precautions:
Constantly practice Kegel exercises that help strengthen the pelvic floor.
Reduction of body weight when overweight.
Follow a balanced diet high in fiber to avoid constipation.
Avoid exertion that causes a significant increase in intra-abdominal pressure, such as lifting excessive weights .
Stop smoking and, in case of respiratory diseases, control cough with specific medications.